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Original article
Coffee consumption and risk of hearing impairment in men and
women
Marcos D. Machado-Fragua
a
, Ellen A. Struijk
a
, Humberto Y
evenes-Briones
a
,
Francisco F
elix Caballero
a
, Fernando Rodríguez-Artalejo
a
,
b
, Esther Lopez-Garcia
a
,
b
,
*
a
Department of Preventive Medicine and Public Health, School of Medicine, Universidad Aut
onoma de Madrid, IdiPaz (Instituto de Investigaci
on Sanitaria
Hospital Universitario La Paz), and CIBERESP (CIBER of Epidemiology and Public Health), Madrid, Spain.
b
IMDEA-Food Institute, CEI UAMþCSIC, Madrid, Spain
article info
Article history:
Received 15 May 2020
Accepted 17 November 2020
Keywords:
Coffee
Hearing impairment
Digit triplet test
UK Biobank
Longitudinal study
summary
Background: Hearing loss is the fifth leading cause of disability in the world. Coffee consumption might
have a beneficial effect on hearing function because of the antioxidant and anti-inflammatory properties
of some of its compounds. However, no previous longitudinal study has assessed the association between
coffee consumption and the risk of hearing impairment.
Objective: To assess the prospective association between coffee consumption and risk of disabling
hearing impairment in middle and older men and women from the UK Biobank study.
Methods: Analytical cohort with 36,923 participants (16,142 men and 20,781 women) [mean (SD): 56.6
(7.8) years, 1.6 (1.4) cups/d, and 7.6 (1.3) dB for age, total coffee consumption and speech reception
threshold in noise at baseline, respectively]. At baseline, coffee consumption was measured with 3e5
multiple-pass 24-h food records. Hearing function was measured with a digit triplet test, and disabling
hearing impairment was defined as a speech reception threshold in noise >-3.5 dB in any physical exam
during the follow-up. Analyses were stratified by sex and Cox regression models were used to assess the
prospective association proposed.
Results: Over 10 years of follow-up, 343 men and 345 women developed disabling hearing impairment.
Among men, compared with those who consumed <1 cup/d of coffee, those who consumed 1, and 2
cups/d had a lower risk of hearing impairment (hazard ratio [95% confidence interval]: 0.72 [0.54e0.97]
and 0.72 [0.56e0.92], respectively; P-trend: 0.01). This association was similar for caffeinated and
decaffeinated coffee, and for filtered and non-filtered coffee, and was stronger in those with obesity
(hazard ratio [95% confidence interval] for consumption of 2 vs. <1 cups/d: 0.39 [0.21e0.74]). No as-
sociation was found between coffee and hearing function among women.
Conclusions: Coffee consumption was associated with lower risk of disabling hearing impairment in men
but not in women. The association appeared to be independent of the coffee type and the preparation
method.
©2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
1. Introduction
Hearing loss is a major public health problem and a common
disorder in the old age [1,2]. Approximately, half of the persons in
their seventh decade and 80% of those 85 years have hearing loss
that is severe enough to affect daily communication [3]. As compared
with adults of similar age with unimpaired hearing, older persons
with hearing loss have higher rates of falls [4], depression [5], de-
mentia [6], cardiovascular diseases [7], hospitalization [8] and death
[8,9]. In addition, the Global Burden of Disease Study has estimated
that hearing loss is the fifth leading cause of disability globally [10].
List of abbreviations: aMED, Alternate Mediterranean Diet score; DTT, Digit
Tripet Test; SRTn, Speech reception threshold in noise; dB, Decibels; BMI, Body
mass index; HR, Hazard ratio; CI, Confidence interval; ROS, Reactive oxygen species;
kHz, Kilohertz.
*Corresponding author. Department of Preventive Medicine and Public Health,
School of Medicine, Universidad Aut
onoma de Madrid, C/ Arzobispo Morcillo, s/n,
28029, Madrid, Spain.
E-mail address: esther.lopez@uam.es (E. Lopez-Garcia).
Contents lists available at ScienceDirect
Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu
https://doi.org/10.1016/j.clnu.2020.11.022
0261-5614/©2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Clinical Nutrition 40 (2021) 3429e3435
For these reasons, it is of special interest to identify the factors that
could reduce the incidence of this health problem. According to a
recent review, some modifiable risk factors of hearing loss include
reduction in exposure to occupational noise, cessation of smoking,
and better management of cardiovascular risk factors [11].
Research about the impact of diet on hearing loss is scarce. There
is some evidence of a beneficial effect of certain dietary patterns
[12e14] and of some specific nutrients, such as antioxidant vita-
mins [15e17], magnesium [15 ,18], and omega-3 fatty acids [19 ,20];
all these effects could be attributed to the anti-inflammatory and
antioxidant properties of these diet components. Coffee con-
sumption has been related to lower risk of cardiovascular disease
[21] and premature mortality [22], and this beneficial effect can be
explained by the strong antioxidant as well as the anti-
inflammatory properties [23] of substances present in coffee.
Therefore, a plausible hypothesis is that coffee consumption also
has a beneficial effect on hearing function. We have only identified
one study assessing this association [24]. Using a cross-sectional
design, the authors found that daily coffee consumers aged
40e64 years had a lower frequency of bilateral hearing loss,
compared with those who consumed coffee occasionally.
The ability to listen requires an adequate hearing in anatomic-
physiological terms but also proper processing of auditory stimuli
in the brain, which implies cognitive processes [25]. Thus, it is
important to assess hearing function with clinically relevant mea-
sures of the functional auditory capacity [26]. Therefore, in this
study, we have examined the association between coffee con-
sumption and risk of disabling hearing function based on a measure
of functional hearing that allows to determine the speech reception
threshold in noise, in a large population-based cohort of middle-
age and older adults from the United Kingdom (UK), participating
in the UK Biobank study [27].
2. Methods
2.1. Study design and participants
We used data from the UK Biobank study, which is a large
population-based cohort study that was established in 2006e2010
throughout the United Kingdom. Participants provided a wide
range of information on health status, demographics and lifestyle.
In addition, they provided several types of biological samples and
underwent a physical examination. A subsample of participants
was followed-up to update information in 2012e2013 and in
2014e2019 [28]. This study was performed under generic ethical
approval obtained by UK Biobank from the National Health Service
National Research Ethics Service (ref 11/NW/0382, 17 June 2011).
2.2. Coffee consumption and other diet variables
Food consumption was collected through five web-based 24-h
recalls (Oxford WebQ). The first one was administered during the
baseline interview (2006e2010) and the remaining four were
completed via online over a 2-year period (2011e2012) [29]. Unlike
standard 24-h diet recalls where the respondents are asked to
remember and report the food consumed, the Web-Q presents
twenty-one food groups and asks the participants if they consumed
any of them over the previous day. Positive answers open addi-
tional questions in which participants have to select the type of
food consumed, and its amount based on standard serving cate-
gories or portions. Thus, the data collection approach used in this
tool could be defined as a hybrid between a 24-h dietary recall and
a FFQ [29]. Coffee consumption was assessed by asking the par-
ticipants whether they consumed caffeinated or decaffeinated
coffee and the method of preparation [filtered or nonfiltered
(cappuccino, latte, espresso, instant)]. The possible responses were:
none, 0.5, 1, 2, 3, 4, 5, and 6 cups/d. A value of 6 was used in our
analyses for those reporting to consume “6 cups/d”. The mean
consumption in cups/d was calculated between the available 24-h
recalls for each participant who completed at least 3 recalls to
obtain an accurate measure of long-term habitual consumption.
Finally, 3 categories of coffee consumption were considered for
total coffee (<1, 1 and 2 cups/d). We also examined the risk of
hearing impairment associated to 1 cup-increment in caffeinated,
decaffeinated, filtered and unfiltered coffee intake.
Total energy and nutrients intake that have previously been
associated with hearing loss (carotene, retinol, folate and saturated
fat) were estimated with standard food composition tables in the
United Kingdom [30], and adjusted for energy using the residual
method [31]. In addition, diet quality was summarized with the
alternate Mediterranean Diet score (aMED) [32]. This score includes
9 items on food consumption and food intake habits characteristic
of the traditional Mediterranean Diet and it is appropriate for non-
Mediterranean populations. The aMED score ranges from 0 to 9,
with a higher score indicating greater adherence to the Mediter-
ranean diet.
2.3. Functional auditory capacity and hearing-related variables
Hearing function was measured at baseline (20 06e2010) and in
two different follow-up waves, the first one in 2012e2013 and the
second one in 2014e2019. Hearing test was performed in the sec-
ond station of the Assessment Centre of the UK Biobank study, so
background noise could be heard due to the open-plan design of
this location. However, participants could choose the volume at
which the test was performed and background noise was kept to a
minimum by the staff to reduce potential for distraction. A digit
triplet test (DTT) was used to determine the speech reception
threshold in noise (SRTn) [28]. The SRTn is a measure of the ability
to recognize speech in noise. Before starting the test, participants
were asked to remove their hearing aid if they had it. In addition,
the volume of the speech was set to the individual's most
comfortable level for each ear. Then, the participant listened to
fifteen sets of three digits presented with background noise and
had to enter each triplet on a keyboard on the touch screen. If the
triplet was correctly identified, the noise level was increased for the
next triplet; otherwise, the noise level was decreased. Each ear was
tested separately, and SRTn was defined as the signal-to-noise-ratio
at which half of the presented digits could be recognized correctly.
The signal-to-noise-ratio could range between 12 and þ8 dB. We
used the SRTn for the best ear for each participant at baseline, and if
the SRTn was only available for one ear, we assumed that it was the
better one. Dawes et al. [33] have established the cut-off points to
categorize the performers in the UK Biobank population as normal
(SRTn <-5.5 dB), insufficient (SRTn -5.5 to -3.5 dB) and poor
hearing (SRTn >-3.5 dB). The outcome in all our analyses was
incident hearing impairment, defined as a SRTn >-3.5 dB in any
physical exam during the follow-up.
The DTT has shown a very good correlation with pure-tone
audiometry (r ¼0.77), which suggests that about 60% of the per-
formance on DTT is explained by standardized audiometric data
[34]. The differences in the psychoacoustic ability of the listener
influence the ability to recognize speech in noise, which explains
the remaining variation [35].
Some variables related to hearing were also ascertained. Loud
music exposure, noisy workplace and tinnitus were assessed by
asking the participants “Have you ever listened to music for more
than 3 h per week at a volume which you would need to shout to be
heard or, if wearing headphones, someone else would need to
shout for you to hear them?“,“Have you ever worked in a noisy
M.D. Machado-Fragua, E.A. Struijk, H. Y
evenes-Briones et al. Clinical Nutrition 40 (2021) 3429e3435
3430
place where you had to shout to be heard?“, and “Do you get or
have you had noises (such as ringing or buzzing) in your head or in
one or both ears that lasts for more than five minutes at a time?“,
respectively [27].
2.4. Mortality
All cause-mortality was obtained from death certificates held by
the National Health Service Information Centre (England and
Wales) and the National Health Service Central register Scotland
(Scotland) [36].
2.5. Other variables
We used baseline data on age, sex, ethnic background, educa-
tional level, smoking status, and alcohol intake. Study participants
were classified following WHO guidelines as abstainers (<0.1 g/d),
moderate drinkers (0.1e39 g/d in men and 0.1e23 g/d in women),
and heavy drinkers (40 g/d in men and 24 g/d in women) [37].
Weight and height were measured under standardized conditions,
body mass index (BMI) was calculated as weight (kg) divided by
height (m) squared, and obesity was defined as BMI 30 kg/m
2
.
Physical activity (metabolic equivalent tasks-hours/week) was
evaluated with questions from the Short International Physical
Activity Questionnaire [38]. Cognitive function was approached
through the reaction time test, which showed 12 rounds of pairs of
cards to each participant, which had to press a button as quickly as
possible if both cards were the same. Therefore, the test allows to
calculate the average reaction time (milliseconds) of each partici-
pant to recognize the pairs of cards; a longer reaction time indi-
cated a worse cognitive status [39,40]. Finally, diagnoses of
diabetes, hypertension and cancer and use of medication were self-
reported by the participants.
2.6. Statistical analyses
For the current analysis, we selected those participants who
provided a minimum of 3 web-based 24-h recall questionnaires of
diet (n ¼41,475). Of them, we excluded 195 participants with
implausible high or low energy intake (outside the range of
800e5000 kcal/d for men and 500e4000 for women), 1096 with
missing data on coffee consumption, 2891 without a hearing test at
baseline, and 370 with prevalent hearing impairment. This resulted
in an analytical sample of 36,923 men and women (Supplemental
Fig. 1).
Participants were classified according to baseline coffee con-
sumption. Differences in sociodemographic characteristics, lifestyle
and prevalence of different diseases across categories of coffee
consumption were reported as a mean and standard deviation for
continuous variables and percentage for categorical variables. P
values were calculated using the Student's Ttest, Chi square test or
analysis of the variance, as appropriate.
We calculated person-years of follow-up from the date of the
baseline questionnaire until the date of the outcome, death, loss to
follow-up, or the end of the study if not hearing impairment was
detected in any of the physical examinations performed during the
follow-up (March 2019), whichever came first. Several Cox
regression models were built to assess the association between
coffee intake and disabling hearing impairment. The first model
was adjusted for age. A second model was additionally adjusted for
other potential confounders including: social and lifestyle variables
(education, smoking, alcohol consumption, BMI, physical activity,
energy intake, diet quality, loud music exposure, noisy workplace);
cognitive function, since the DTT performs better in participants
with higher psychoacoustic ability; prevalence of tinnitus because
it may be related to impaired speech perception[41]; hypertension,
diabetes and cancer to account for the synergistic effect of chronic
diseases on degenerative processes associated with aging [42]; and
for the use of ototoxic medication, including aspirin and ibuprofen.
A third model was further adjusted for the intake of nutrients
associated previously with hearing impairment, such as carotene,
retinol, folate, and polyunsaturated fat. Moreover, we assessed the
separate association of caffeinated and decaffeinated coffee, and
filtered and unfiltered coffee and hearing impairment, using
models additionally adjusted for the other types of coffee. We
estimated the hazard ratios (HR) and its 95% confidence interval
(CI) for each category of coffee consumption, compared with the
category of lowest consumption. We also modeled coffee intake as
a continuous variable to investigate the linear doseeresponse
relationship. Likewise, we calculated the risk of hearing impair-
ment associated with a 1-cup/d increment for the different types of
coffee consumed.
We conducted the analyses separately in men and women since
we found a statistically significant interaction between coffee and
sex in relation to incident hearing impairment (Pfor interaction:
0.02). We also conducted several sensitivity analyses: a) among
those with optimal hearing at baseline, to understand whether the
effect of coffee depends on the baseline status; b) among those with
British background, as a proxy for native English speakers, since
non-native may perform worse than native speakers; c) taking the
non-consumers as reference, to understand the impact of reverse
causation in the studied association; and d) removing from the
models the adjustment for tinnitus, since it is unclear if this dis-
order might be part of the hearing loss process. Moreover, we
tested if the main results varied by categories of age, diet quality,
physical activity and obesity; to this end, we used likelihood-ratio
tests that compared models with and without cross-product
interaction terms.
Finally, to test the non-linear trends of risk, we used restricted
cubic-splines with three knots for total coffee consumption and risk
of hearing impairment, separately in men and women. We con-
ducted all the analyses using Stata (version 15.0; Stata Corp., Col-
lege Station). This manuscript follows the Strengthening the
Reporting of Observational Studies in Epidemiology (STROBE)
recommendations.
3. Results
The mean (SD) intake of caffeinated and decaffeinated coffee
was 1.30 (0.72) and 0.25 (0.57) cups/d, respectively. The most
frequently method of preparation was non-filtered coffee [1.14
(0.74) cups/d vs 0.40 (0.57) of filtered]. Characteristics of the study
participants according to categories of coffee consumption were
similar between men and women (Table 1). Compared to those
consuming <1 cup/d of coffee, those with highest consumption
were older, had a higher educational level and were more likely to
be current smokers and heavy drinkers. Also, they had higher BMI,
higher intake of energy and retinol but lower intake of folate, and
were more likely to have a diagnosis of diabetes; by contrast, they
were less exposed to loud music or to noise in their workplace.
Over 11.9 years of follow-up, 343 men (2.12%) and 345 women
(2.08%) developed disabling hearing impairment. Among men,
compared with those who consumed <1 cup/d, participants who
consumed 1 and 2 cups/d had lower risk in the full-adjusted
analysis (HR: 0.72; 95% CI: 0.54e0.97 and 0.72; 95% CI:
0.56e0.92, respectively; P-trend: 0.01). Among the confounders,
tinnitus accounted for most of the attenuation of the risk estimates
between the crude model versus the adjusted model. We estimated
that one cup/d increment in coffee consumption was associated
with a 15% lower risk (95% CI: 4e25) of hearing impairment. On the
M.D. Machado-Fragua, E.A. Struijk, H. Y
evenes-Briones et al. Clinical Nutrition 40 (2021) 3429e3435
3431
contrary, no association was found among women (Table 2). These
results were similar when we only included in the analyses par-
ticipants with optimal hearing at baseline or in participants with
English background (Supplemental Tables 1 and 2) or when we
took the non-consumers as the reference group (Supplemental
Table 3). Removing from the models the adjustment for tinnitus
did not modify the estimates of the studied association
(Supplemental Table 5.
Likewise, we observed similar associations for caffeinated vs.
decaffeinated coffee and for filtered vs. unfiltered coffee, among
men (Fig. 1). In sensitivity analysis in subgroups of participants, we
found a statistically significant interaction between coffee con-
sumption and obesity in men (Pfor interaction: 0.03), so that obese
men who consumed 2 cups/d of coffee had a lower risk of hearing
impairment. No other significant interactions were found for age,
diet quality or physical activity, neither in men nor in women
(Supplemental Table 4).
Finally, sex-based differences were again evidenced in non-
parametric analyses; we observed a decreased risk among men
who consumed up to a maximum of 4.5 cups/d of total coffee,
whereas we did not find any trend for women (Fig. 2).
4. Discussion
We assessed the relationship between coffee consumption and
hearing function in the UK Biobank study over a period of 11 years
of follow-up and we found that coffee consumption was associated
with lower risk of disabling hearing impairment in men but not in
women. This result was robust and appeared to be independent of
the coffee type or the preparation method.
Hearing loss is a reduction in the sensitivity of sound and its
occurrence over the life course is mainly due to exposure to
ototoxic drugs and noise or as result of the aging process [43]. The
impact of diet on hearing loss is explained by several mechanisms,
including providing essential nutrients for adequate cochlear blood
supply, influencing stress response, immune response, car-
diometabolic status, mitochondrial dysfunction and auditory neu-
rodegeneration [13]. In this study, we found a significant
interaction between coffee consumption and sex on the risk of
hearing impairment. Although it was a non-anticipated finding, it
could be partly explained by some sex differences in brain
biochemistry, physiology, structure and function between men and
women [44,45]. For example, men have a longer length of the co-
chlea than women, which could influence the auditory brainstem
responses [45]. Likewise, some studies reported differences by sex
in the prevalence and progression of age-related hearing loss, so
that men had more frequently a higher hearing threshold [46] and a
quicker pure-tone hearing threshold decline than women [45]. In
addition, results from several studies suggest that estrogen plays a
beneficial role in the cochlear function and that high circulating
levels protects against age-related hearing loss. Thus, among
women, the impact of nutrition on auditory function would be less
relevant than in men since it could be mostly dependent on the
level of estrogen synthesis, which fluctuates across the menstrual
Table 1
Participants’characteristics at baseline across the categories of coffee consumption (N ¼36,923).
Men (n ¼16,142) Women (n ¼20,781)
Total coffee consumption, cups/d Total coffee consumption, cups/d
<11 2<11 2
Participants, n 5084 4158 6900 7477 5534 7770
Age, y 56.5 ±8.1 57.9 ±7.7 57.7 ±7.7
c
54.9 ±7.8 56.6 ±7.7 56.7 ±7.6
Educational level
Primary 7.6 6.0 5.8 6.1 4.9 5.6
Secondary 33.2 28.1 28.7 33.2 29.2 30.3
University 59.2 65.9 65.5
c
60.7 65.9 64.1
c
Current smoker, % 6.8 6.4 9.2
c
4.3 4.2 7.3
c
Heavy drinker
a
16.2 18.4 18.7
c
14.2 18.1 19.7
BMI, Kg/m
2
27.2 ±4.1 26.7 ±3.9 27.5 ±4.2
c
26.1 ±5.0 25.9 ±4.7 26.7 ±4.9
c
Physical activity, METs-h/week 41.4 ±41.6 40.2 ±38.1 40.2 ±38.9 39.4 ±35.7 38.8 ±34.5 38.9 ±35.8
c
Energy intake, kcal/d 2252 ±553 2275 ±510 2321 ±522
c
1935 ±447 1962 ±424 1980 ±433
c
aMED score 3.9 ±1.8 4.1 ±1.8 3.8 ±1.7 4.4 ±1.8 4.5 ±1.8 4.3 ±1.7
c
Intake of carotene,
m
g/d 2823 ±2009 2866 ±1844 2839 ±1831 3314 ±2150 3322 ±2029 3294 ±2045
Intake of retinol,
m
g/d 335 ±152 343 ±147 362 ±150
c
298 ±132 312 ±131 319 ±133
c
Intake of folate,
m
g/d 322 ±100 319 ±93 314 ±95
c
294 ±89 292 ±86 287 ±88
c
Intake of polyunsaturated fat, g/d 15.5 ±6.2 15.3 ±5.9 15.5 ±5.9 13.8 ±5.3 13.5 ±5.0 13.5 ±5.2
a
SRTn (best ear at baseline), dB 7.59 ±1.32 7.57 ±1.32 7.61 ±1.29 7.59 ±1.30 7.57 ±1.27 7.59 ±1.28
Loud music exposure, % 18.9 15.8 16.7
c
10.2 7.9 8.6
c
Noisy workplace, % 17.6 14.7 15.7
c
9.1 7.2 7.6
c
Tinnitus, % 20.8 20.3 20.8 14.9 14.3 14.4
Reaction time test, msec 543 ±111 547 ±110 544 ±107 555 ±111 560 ±109 562 ±109
c
Self-reported diseases, %
Hypertension 32.6 31.3 31.2 20.5 20.8 20.8
Diabetes 5.8 4.7 5.9
a
2.7 2.3 3.2
b
Cancer 6.2 6.5 6.3 9.0 9.8 9.2
Aspirin use, % 15.0 15.5 16.0 7.3 6.9 7.2
Ibuprofen use, % 8.2 9.5 9.8 14.4 14.1 15.1
Type of coffee, cups/d
Caffeinated 0.21 ±0.28 1.16 ±0.47 2.70 ±1.36 0.19 ±0.27 1.08 ±0.51 2.44 ±1.44
Decaffeinated 0.03 ±0.12 0.17 ±0.39 0.41 ±1.06 0.04 ±0.14 0.23 ±0.45 0.61 ±1.26
Filtered 0.06 ±0.17 0.40 ±0.52 0.78 ±1.08 0.06 ±0.15 0.41 ±0.52 0.70 ±0.99
Unfiltered 0.18 ±0.26 0.93 ±0.55 2.33 ±1.43 0.18 ±0.25 0.90 ±0.54 2.34 ±1.43
Values are means ±SDs unless stated otherwise.
aMED score: alternate Mediterranean Diet score.
SRTn: speech reception threshold in noise.
a
P<0.05
b
P<0.01
c
P<0.001.
a
Heavy drinker: 40 g/d of alcohol in men and 24 g/d in women.
M.D. Machado-Fragua, E.A. Struijk, H. Y
evenes-Briones et al. Clinical Nutrition 40 (2021) 3429e3435
3432
cycle and the menopausal status [47]. By contrast, among men,
with a low and constant estrogen levels, the impact of a dietary
exposure with plausible beneficial effects might be more evident.
Increased production of reactive oxygen species (ROS), activa-
tion of mitochondrial apoptotic pathways and endoplasmic retic-
ulum stress are some of the proposed mechanisms involved in
hearing loss [43]. Also, the accumulation of mitochondrial DNA
mutations contributes to aging and to the development of degen-
erative diseases in animal models [48] and in humans [49]. In
addition, dysfunctional mitochondria increase the production and
accumulation of ROS, which decreases the mitochondrial mem-
brane potentials and activate apoptotic pathways that lead to the
death of hair cells in the inner ear [43]. Therefore, protecting the
mitochondria against the effect of ROS through antioxidant com-
pounds might serve to prevent degenerative diseases such as
hearing loss [48]. Coffee is one of the main sources of antioxidant
compounds in diet. Antioxidant compounds in coffee brews, such
as chlorogenic acid, may reduce the concentration of ROS and, thus,
protect against oxidative stress [23]. In a study with 9877 in-
dividuals, Ishizaka et al. [50] found that coffee intake was inversely
associated with derivatives of reactive oxygen metabolites in men
but not in women, which is in line with the sex differences in the
effect of coffee on hearing loss observed in our study.
We have also found a stronger association between coffee and
hearing impairment in men with obesity. It has been hypothesized
that obesity could increase the risk of hearing loss through higher
levels of inflammation and oxidative stress, as well as the devel-
opment of comorbidities [51]. A study on older adults suggested a
positive association between BMI and hearing thresholds in cross-
sectional analysis that became non-significant in longitudinal
analysis, probably due to the small sample size (n ¼636) [52].
However, Hu et al. [53], in a prospective cohort study with 48,549
Asian participants aged 20e64 years, found that obese individuals
had approximately 30% higher risk of hearing loss at 4 kHz, and also
Table 2
Hazard ratios (95% confidence interval) for the association between total coffee consumption and the risk of hearing impairment in the UK Biobank study stratified by sex
(N ¼36,923).
Total coffee consumption, cups/d Continuous per 1-cup/d increment
<11 2 P-trend
Men (n ¼16,142)
Person-years 20,273 16,241 27,988
N 5084 4158 6900
Cases, n 125 76 142
Crude model 1.00 0.80 (0.60e1.06) 0.78 (0.61e0.99) 0.05 0.88 (0.78e1.00)
Model 1
a
1.00 0.71 (0.54e0.95) 0.70 (0.55e0.89) 0.005 0.84 (0.74e0.95)
Model 2
b
1.00 0.72 (0.54e0.96) 0.71 (0.55e0.90) 0.007 0.84 (0.74e0.95)
Model 3
c
1.00 0.72 (0.54e0.97) 0.72 (0.56e0.92) 0.01 0.85 (0.75e0.96)
Women (n ¼20,781)
Person-years 28,412 20,965 29,843
N 7477 5534 7770
Cases, n 124 81 140
Crude model 1.00 0.90 (0.68e1.19) 1.04 (0.82e1.33) 0.70 1.02 (0.91e1.16)
Model 1
a
1.00 0.83 (0.62e1.10) 0.96 (0.75e1.22) 0.76 0.98 (0.87e1.11)
Model 2
b
1.00 0.80 (0.61e1.07) 0.92 (0.72e1.18) 0.55 0.96 (0.85e1.09)
Model 3
c
1.00 0.82 (0.61e1.09) 0.91 (0.71e1.17) 0.49 0.96 (0.84e1.09)
a
Cox model adjusted for age.
b
Cox model additionally adjusted for educational level (primary, secondary, university), smoking status (never smoker, former smoker, current smoker), alcohol con-
sumption (none, moderate, heavy drinker), BMI (tertiles of kg/m
2
), physical activity (tertiles of MET-h/week), energy intake (tertiles of kcal/d), loud music exposure (yes/no),
noisy workplace (yes/no), reaction time test (tertiles of msec), tinnitus, hypertension, diabetes, cancer, and ototoxic medication (aspirin and ibuprofen use).
c
Cox model additionally adjusted for aMED (tertiles), and for intake of carotene (quintiles of
m
g/d), retinol (quintiles of
m
g/d), folate (quintiles of
m
g/d), and polyunsaturated
fat (quintiles of g/d).
Fig. 1. Hazard ratios (95% confidence interval) per 1 cup-increment for the association between the different types of coffee and the risk of hearing impairment in the UK Biobank
study stratified by sex. Analyses are adjusted for age, educational level (primary, secondary, university), smoking status (never smoker, former smoker, current smoker), alcohol
consumption (none, moderate, heavy drinker), BMI (tertiles of kg/m
2
), physical activity (tertiles of MET-h/week), energy intake (tertiles of kcal/d), loud music exposure (yes/no),
noisy workplace (yes/no), reaction time test (tertiles of msec), tinnitus, hypertension, diabetes, and cancer, aMED (tertiles of points), intake of carotene (quintiles of
m
g/d), retinol
(quintiles of
m
g/d), folate (quintiles of
m
g/d), potassium (quintiles of mg/d), polyunsaturated fat (quintiles of g/d), ototoxic medication (aspirin and ibuprofen use). and the other type
of coffee.
M.D. Machado-Fragua, E.A. Struijk, H. Y
evenes-Briones et al. Clinical Nutrition 40 (2021) 3429e3435
3433
that metabolically unhealthy status conferred an additional risk.
Thus, because obese men have a higher risk of hearing loss, it is
plausible that the protective effect of coffee could also be more
evident among them.
Our study has several strengths, including the prospective
design and the large sample size. The use of the DTT was another
strength, since it allowed to better approximating the loss of
functional auditory capacity. Lastly, our analyses were adjusted for
many potential confounders, including diseases that may affect
hearing, as well as exposure to loud music and noise at work and
ototoxic medication. This study also has some limitations. Diet
measurement was performed approximately one year later than
baseline hearing function measurement; therefore we assumed
that this dietary information indicates habitual diet at baseline.
Coffee consumption was self-reported, so some misreporting and
misclassification of dietary intake cannot be ruled out; however, we
only included participants with at least three 24-h dietary recalls to
reflect the habitual diet. Since diet information was only obtained
in a 2-y period, possible changes in consumption over the years
could not be accounted for. In addition, compared with the rest of
UK Biobank volunteers, those who completed at least one WebQ
tended to be white, female, slightly older, less deprived and more
educated, which is typical of health-conscious volunteer-based
studies [29]. Thus, extrapolation of the results to the general pop-
ulation should be made with caution. Although the DTT is corre-
lated with pure-tone audiometry measurement, it is also
influenced by cognitive status and education, as well as for the fact
that non-native English speakers may have lower ability to recog-
nize the words used in the test. However, our results were adjusted
for educational level and cognitive status, approximated by the
reaction time test, and remained significant when only those with
British ethnic background were included in the analysis; so it is not
likely that these factors could entirely explained our results. Lastly,
we could not exclude participants with conductive hearing loss.
In conclusion, habitual coffee consumption was associated with
a lower risk of disabling hearing impairment in men, but not in
women. We found no differences between the type of coffee or the
preparation method on the risk. Whether this association may be
causal merits more research.
Sources of support
This work was supported by FIS grants 16/609 and 16/1512
(Instituto de Salud Carlos III, State Secretary of RþDþI, and
FEDER/FSE), the ATHLOS project (EU H2020- Project ID: 635316)
and the JPI HDHL (SALAMANDER project). The funding agencies
had no role in the study design, data analysis, interpretation of
results, writing of the report, and in the decision to submit the
article for publication.
Conflict of interest
The authors declare that they have no conflicts of interest.
Authors’contributions
The authors’contributions were as follows: MMF, EAS and ELG:
designed the research; MMF: performed the statistical analyses; all
authors: contributed to interpretation of the results; MMF, EAS and
ELG: drafted the manuscript; ELG: supervised the conduct of
research and had primary responsibility for final content; and all
authors: reviewed the manuscript for important intellectual con-
tent, and read and approved the final manuscript.
Acknowledgements
This research has been conducted with the use of the UK Bio-
bank Resource under application number 29009.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.clnu.2020.11.022.
References
[1] Olusanya BO, Neumann KJ, Saunders JE. The global burden of disabling hearing
impairment. A call to action. Bull World Health Organ 2014;92(5):367e73.
[2] Graydon K, Waterworth C, Miller H, Gunasekera H. Global burden of hearing
impairment and ear disease. J Laryngol Otol 2019;133(1):18e25.
[3] Agrawal Y, Platz EA, Niparko JK. Prevalence of hearing loss and differences by
demographic characteristics among US adults: data from the National Health
and Nutrition Examination Survey, 1999-2004. Arch Intern Med
2008;168(14):1522e30.
[4] Jiam NT, Li C, Agrawal Y. Hearing loss and falls: a systematic review and meta-
analysis. Laryngoscope 2016;126(11):2587e96.
[5] Lawrence BJ, Jayakody DMP, Bennett RJ, Eikelboom RH, Gasson N,
Friedland PL. Hearing loss and depression in older adults: a systematic review
and meta-analysis. Gerontologist 2019. https://doi.org/10.1093/geront/
gnz009 [Epub ahead of print].
[6] Gurgel RK, Ward PD, Schwartz S, Norton MC, Foster NL, Tschanz JT. Rela-
tionship of hearing loss and dementia: a prospective, population-based study.
Otol Neurotol 2014;35(5):775e81.
Fig. 2. Multivariable adjusted spline curves of relation between total coffee and the risk of hearing impairment in men and women. Covariates were age, educational level
(primary, secondary, university), smoking status (never smoker, former smoker, current smoker), alcohol consumption (none, moderate, heavy drinker), BMI (tertiles of kg/m
2
),
physical activity (tertiles of MET-h/week), energy intake (tertiles of kcal/d), loud music exposure (yes/no), noisy workplace (yes/no), reaction time test (tertiles of msec), tinnitus,
hypertension, diabetes, and cancer, aMED (tertiles), intake of carotene (quintiles of
m
g/d), retinol (quintiles of
m
g/d), folate (quintiles of
m
g/d), and polyunsaturated fat (quintiles of g/
d), and ototoxic medication (aspirin and ibuprofen use).
M.D. Machado-Fragua, E.A. Struijk, H. Y
evenes-Briones et al. Clinical Nutrition 40 (2021) 3429e3435
3434
[7] McKee MM, Stransky ML, Reichard A. Hearing loss and associated medical
conditions among individuals 65 years and older. Disabil Health J 2018;11(1):
122e5.
[8] Hsu AK, McKee M, Williams S, Roscigno C, Crandell J, Lewis A, et al. Associa-
tions among hearing loss, hospitalization, readmission and mortality in older
adults: a systematic review. Geriatr Nurs 2019;40(4):367e79.
[9] Lin HW, Mahboubi H, Bhattacharyya N. Hearing difficulty and risk of mor-
tality. Ann Otol Rhinol Laryngol 2019;128(7):614e8.
[10] Institute for Health Metrics and Evaluation IHME. Findings from the global
burden of disease study 2017. Seattle, WA: IHME; 2018.
[11] Cunningham LL, Tucci DL. Hearing loss in adults. N Engl J Med 2017;377(25):
2465e73.
[12] Curhan SG, Wang M, Eavey RD, Stampfer MJ, Curhan GC. Adherence to
healthful dietary patterns is associated with lower risk of hearing loss in
women. J Nutr 2018;148(6):944e51.
[13] Spankovich C, Le Prell CG. Healthy diets, healthy hearing: national health and
Nutrition Examination Survey, 1999-2002. Int J Audiol 2013;52(6):369e76.
[14] Curhan SG, Halpin C, Wang M, Eavey RD, Curhan GC. Prospective study of
dietary patterns and hearing threshold decline. Am J Epidemiol 2019. https://
doi.org/10.1093/aje/kwz223.
[15] Choi YH, Miller JM, Tucker KL, Hu H, Park SK. Antioxidant vitamins and
magnesium and the risk of hearing loss in the US general population. Am J
Clin Nutr 2014;99(1):148e55.
[16] Gopinath B, Flood VM, McMahon CM, Burlutsky G, Spankovich C, Hood LJ,
et al. Dietary antioxidant intake is associated with the prevalence but not
incidence of age-related hearing loss. J Nutr Health Aging 2011;15(10):
896e900.
[17] Durja J, Verhoef P, Anteunis LJ, Schouten E, Kok FJ. Effects of folic acid sup-
plementation on hearing in older adults: a randomized, controlled trial. Ann
Intern Med 2007;146(1):1e9.
[18] Attias J, Sapir S, Bresloff I, Reshef-Haran I, Ising H. Reduction in noise-induced
temporary threshold shift in humans following oral magnesium intake. Clin
Otolaryngol Allied Sci 2004;29(6):635e41.
[19] Dullemeijer C, Verhoef P, Brouwer IA, Kok FJ, Brummer RJ, Durga J. Plasma
very long-chain n-3 polyunsaturated fatty acids and age-related hearing loss
in older adults. J Nutr Health Aging 2010;14(5):347e51.
[20] Gopinath B, Flood VM, Rochtchina E, McMahon CM, Mitchell P. Consumption
of omega-3 fatty acids and fish and risk of age-related hearing loss. Am J Clin
Nutr 2010;92(2):416e21.
[21] Ding M, Bhupathiraju SN, Satija A, van Dam RM, Hu FB. Long-term coffee
consumption and risk of cardiovascular disease: a systematic review and a
dose-response meta-analysis of prospective cohort studies. Circulation
2014;129:643e59.
[22] Gunter MJ, Murphy N, Cross AJ, Dossus L, Dartois L, Fagherazzi G, et al. Coffee
drinking and mortality in 10 European countries: a multinational cohort
study. Ann Intern Med 2017;167(4):236e47.
[23] Liang N, Kitts D. Role of chlorogenic acids in controlling oxidative and in-
flammatory stress conditions. Nutrients 2016;8:E16.
[24] Lee SY, Jung G, Jang MJ, Suh MW, Lee JH, Oh SH, et al. Association of coffee
consumption with hearing and tinnitus based on a national population-based
survey. Nutrients 2018;10:E1429.
[25] Moore DR, Edmondson-Jones M, Dawes P, Fortnum H, McCormack A,
Pierzycki RH, et al. Relation between speech-in-noise threshold, hearing loss
and cognition from 40-69 years of age. PloS One 2014;9(9):e107720.
[26] Phatak SA, Brungart DS, Zion DJ, Grant KW. Clinical assessment of functional
hearing deficits: speech-in-noise performance. Ear Hear 2019;40(2):426e36.
[27] Sudlow C, Gallacher J, Allen N, Beral V, Burton P, Danesh J, et al. UK Biobank:
an open access resource for identifying the causes of a wide range of complex
diseases of middle and old age. PLoS Med 2015;12(3):e1001779.
[28] UK Biobank. UK Biobank website. [Internet]. 2019. Available from: https://
ukbiobank.ac.uk/. [Accessed 29 May 2019].
[29] Galante J, Adamska L, young A, Young H, Littlejohns TJ, Gallacher J, et al. The
acceptability of repeat Internet-based hybrid diet assessment of previous 24-h
dietary intake: administration of the Oxford WebW in UK Biobank. Br J Nutr
2016;115(4):681e6.
[30] Holland B, Welch A, Unwin I, Buss DH, Paul AA, Southgate DAT. McCance and
widdowson's. The composition of foods. 5th ed. Cambridge: Royal Society of
Chemistry; 1991.
[31] Willett WC. Nutritional Epidemiology. 3rd ed. New York: Oxford University
Press; 2012.
[32] Fung TT, McCullough ML, Newby PK, Manson JE, Meigs JB, Rifai N, et al. Diet-
quality scores and plasma concentrations of markers of inflammation and
endothelial dysfunction. Am J Clin Nutr 2005;82(1):163e73.
[33] Dawes P, Fortnum H, Moore DR, Emsley R, Norman P, Cruickshanks K, et al.
Hearing in middle age: a population snapshot of 40-to 69-year olds in the
United Kingdom. Ear Hear 2014;35(3):44e51.
[34] Smits C, Kapteyn TS, Houtgast T. Development and validation of an automatic
speech-in-noise screening test by telephone. Int J Audiol 2004;43:15e28.
[35] Keidser G, Seeto M, Rudner M, Hygge S, R€
onnberg J. On the relationship be-
tween functional hearing and depression. Int J Audiol 2015;54:653e64.
[36] Wade KH, Carslake D, Sattar N, Davey Smith G, Timpson NJ. BMI and mortality
in UK Biobank: revised estimates using mendelian randomization. Obesity
(Silver Spring) 2018;26(11):1796e806.
[37] Ortol
a R, García-Esquinas E, Gal
an I, Guallar-Castill
on P, L
opez-García E,
Banegas JR, et al. Patterns of alcohol consumption and risk of falls in older
adults: a prospective cohort study. Osteoporos Int 2017;28(11):3143e52.
[38] Craig CL, Marshall AL, Sj€
ostr€
om M, Bauman AE, Booth ML, Ainsworth BE, et al.
International physical activity questionnaire: 12-country reliability and val-
idity. Med Sci Sports Exerc 2003;35(8):1381e95.
[39] Lyall DM, Cullen B, Allerhand M, Smith DJ, Mackay D, Evans J, et al. Cognitive
test scores in UK Biobank: data reduction in 480,416 participants and longi-
tudinal stability in 20,346 participants. PloS One 2016;11(4):e0154222.
[40] Moore DR, Edmondson-Jones M, Dawes P, Fortnum H, McCormack A,
Pierzycki RH, et al. Relation between speech-in-noise threshold, hearing loss
and cognition from 40-69 years of age. PloS One 2014;9(9):e107720.
[41] Oosterloo BC, Homans NC, Goedegebure A. Tinnitus affects speech in noise
comprehension in individuals with hearing loss. Otol Neurotol 2020;41(9):
e1074e81.
[42] Ferrucci L, Gonzalez-Freire M, Fabbri E, Simonsick E, Tanaka T, Moore Z, et al.
Measuring biological aging in humans: a quest. Aging Cell 2020 Feb;19(2):
e13080. https://doi.org/10.1111/acel.13080.
[43] Kamogashira T, Fujimoto C, Yamasoba T. Reactive oxygen species, apoptosis,
and mitocondrial dysfunction in hearing loss. Biomed Res Int 2015:617207.
[44] Lauer AM, Schrode KM. Sex bias in basic and preclinical noise-induced hearing
loss research. Noise Health 2017;19(90):207e12.
[45] Shuster BZ, Depireux DA, Mong JA, Hertzano R. Sex differences in hearing:
probing the role of estrogen signaling. J Acoust Soc Am 2019;145:3656.
[46] Park YH, Shin SH, Byun SW, Kim JY. Age- and gender-related mean hearing
threshold in a highly-screened population: the Korean national health and
nutrition examination survey 2010-2012. PloS One 2016;11(3):e0150783.
[47] Delhez A, Lefebvre P, P
equeux C, Malgrange B, Delacroix L. Auditory function
and dysfunction: estrogen makes a difference. Cell Mol Life Sci 2020;77(4):
619e35.
[48] Kujoth GC, Hiona A, Pugh TD, Someya S, Panzer K, Wogemuth SE, et al.
Mitochondrial DNA mutations, oxidative stress, and apoptosis in mammalian
aging. Science 2015;309(5733):481e4.
[49] Giorgi C, Marchi S, Simoes ICM, Ren Z, Morciano G, Perrone M, et al. Mito-
chondria and reactive oxygen species in aging and age-related diseases. Int
Rev Cell Mol Biol 2018;340:209e344.
[50] Ishizaka Y, Yamakado M, Toda A, Tani M, Ishizaka N. Relationship between
coffee consumption, oxidant status, and antioxidant potential in the Japanese
general population. Clin Chem Lab Med 2013;51(10):1951e9.
[51] Dhanda N, Taheri S. A narrative review of obesity and hearing loss. Int J Obes
(Lond) 2017;41(7):1066e73.
[52] Croll PH, Voortman T, Vernooij MW, Baatenburg de Jong RJ, Lin FR,
Rivadeneira F, et al. The association between obesity, diet quality and hearing
loss in older adults. Aging (Albany NY) 2019;11(1):48e62.
[53] Hu H, Tomita K, Kuwahara K, Yamamoto M, Uehara A, Kochi T, et al. Obesity
and risk of hearing loss: a prospective cohort study. Clin Nutr 2020;39(3):
870e5.
M.D. Machado-Fragua, E.A. Struijk, H. Y
evenes-Briones et al. Clinical Nutrition 40 (2021) 3429e3435
3435
